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          <h1 class="post-title" itemprop="name headline">《Newman and Carranza's Clinical Periodontology》读书笔记4</h1>
        

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        <p>第33章 影像学辅助牙周病诊断<br>正常牙槽骨在X片上是一个薄的，透射的线，临近牙周韧带以及牙槽嵴顶，被称为硬骨板(lamina dura)。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/01.jpg"><br>牙周病的骨破坏<br>早期破坏改变在X片上看不到。因此如果在X片上看到轻微的改变提示牙周病已经处于进展期而不是早期了。最早期的牙周病必须通过临床检查来确定。<br>骨丧失：影像倾向于低估牙槽骨丧失的严重程度。牙槽嵴高度与影像学显示的差别从0到1.6mm，多数情况与X片角度有关。骨量：X片主要是显示剩余牙槽骨的量，而不是吸收程度。吸收程度主要靠与正常牙槽骨水平相比较而得到。多数学者建议牙槽嵴顶与釉牙骨质界的距离2mm是正常的。破坏的分布：与破坏因素的分布有关。<br>牙槽骨破坏的类型<br>分为水平型骨吸收（牙槽骨高度降低，沿着牙长轴方向）和角度或拱形吸收(角度或垂直骨吸收）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/02.jpg"><br>影像学不能呈现弹坑样(crater-like）缺损的形态或深度，也不能显示患牙的颊舌侧范围。近远中的骨破坏也有可能被解剖结构的重叠所阻挡。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/03.jpg"><br>牙齿间的骨缺损有可能是槽型的缺损，很难通过X片看到。<br>最后，影像学只能看到静态结果，牙槽骨是否持续吸收只能通过临床检查才能知道。<br>牙周病的影像学表现：<br>①牙槽嵴顶硬骨板模糊消失，影像连续性破坏是牙周病的早期影像学表现；<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/04.jpg"><br>②进行性牙槽骨破坏和牙周间隙增宽导致在牙槽嵴顶近远中的影像中出现一个楔形的透射影像。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/05.jpg"><br>③破坏范围扩大，通过牙槽嵴，降低牙槽骨高度。牙槽骨可出现偏侧侵蚀。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/06.jpg"><br>④由于炎症和牙槽骨再吸收的扩展，牙间隔牙槽骨高度进行性降低。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/07.jpg"><br>⑤常常可以看到一条穿过牙根的阻射的影像，这条阻射线是颊侧和舌侧骨板局部或完全破坏的界线。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/08.jpg"><br>根分叉病变：主要还是靠临床检查，由于解剖结构重叠，影像学检查价值有限。一个普遍原则是骨破坏的程度要比影像学上看到的要严重。<br>角度不一样，根分叉影像大不一样。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/09.jpg"><br>一些诊断建议：<br>①根分叉区域轻微的影像学改变要进行仔细的临床检查，尤其是临近牙根有骨吸收的时候。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/10.jpg"><br>②根分叉区域密度减低而且可以见到骨小梁轮廓的时候，应怀疑为根分叉病变。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/11.jpg"><br>③如果有磨牙的一个牙根的骨丧失，也许可以假设根分叉也受到了影响。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/12.jpg"><br>牙周脓肿：往往没有直接的影像学表现。<br>①破坏的阶段：在早期阶段，急性期，患者疼痛明显，但是没有影像学改变。<br>②广泛的骨破坏和牙槽骨的形态学改变。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/13.jpg"><br>③脓肿的定位：可以用从瘘道口插牙胶的方法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/14.jpg"><br>用插牙胶尖的方法还可以确定深袋的骨吸收水平。左图看不到明显的骨破坏，右图是插了牙胶的。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/15.jpg"><br>局限性侵袭性牙周炎<br>①开始时，上下颌切牙和第一磨牙区域有骨吸收，常是双向的，导致一个垂直的，虫蚀样的破坏类型。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/16.jpg"><br>②随着疾病的进展，牙槽骨吸收会变得广泛但在前磨牙区域仍较轻。<br>咬合创伤<br>可以造成硬骨板变薄，牙槽嵴形态改变，牙周膜间隙宽度改变，周围牙槽骨骨密度改变等。咬合创伤造成的损伤在颊舌侧更加明显，因为近远中有邻牙支持。因此邻接面的轻微破坏往往提示颊舌侧有大的破坏。<br>①硬骨板的破坏在根尖，根分叉和边缘区域较明显。这种破坏导致牙周膜间隙(PDL)增宽。这是牙周组织适应负重增加的改变。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/17.jpg"><br>更严重的咬合创伤缺损会导致深的角形骨吸收，再加上龈缘感染，也许会导致一个深的骨内袋形成。在晚期，这些病损扩展到根尖周，产生一个广泛的，根尖透射影像。<br>CBCT的使用，避免了解剖结构的重叠，图像变形等问题。<br>在X片上没问题的牙齿，在CBCT上发现远中有骨破坏。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/18.jpg"><br>结论：影像学检查应该是牙周病评估和随访的一个部分，影像学评估应该每2年做一次。<br>课后病例题目有意思，看看。CBCT图像。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/19.jpg"><br>①邻牙箭头那里是不是龋坏？不是，那个透射影像是邻牙牙冠在CBCT上的伪影。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/20.jpg"><br>②牙周膜间隙增宽，发生在近中，颊侧和远中表面？正确，看图说话。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/21.jpg"><br>③牙周膜间隙增宽扩展到牙槽嵴顶以及接近根尖区?正确，骨缺损是牙周牙髓联合缺损。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0062-lcyzbxbj04/22.jpg"><br>④近远中牙根纵裂？没有，是CBCT伪影。</p>
<p>总结：影像学手段在牙周炎诊断中很有帮助，但要注意影像学表现的病损程度要低于实际程度，而且还有解剖结构重叠，拍摄角度等问题。这几天有网友微信打赏我，感谢了！接下来两天报了个班去学习了，停更。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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